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Meta-Analysis
. 2020 Jul 20;7(7):CD013684.
doi: 10.1002/14651858.CD013684.

Psychological interventions to foster resilience in healthcare students

Angela M Kunzler  1 , Isabella Helmreich  1 , Jochem König  2 , Andrea Chmitorz  3   4 , Michèle Wessa  1   5 , Harald Binder  6 , Klaus Lieb  1   4
Affiliations
Meta-Analysis

Psychological interventions to foster resilience in healthcare students

Angela M Kunzler et al. Cochrane Database Syst Rev. .

Abstract

Background: Resilience can be defined as maintaining or regaining mental health during or after significant adversities such as a potentially traumatising event, challenging life circumstances, a critical life transition or physical illness. Healthcare students, such as medical, nursing, psychology and social work students, are exposed to various study- and work-related stressors, the latter particularly during later phases of health professional education. They are at increased risk of developing symptoms of burnout or mental disorders. This population may benefit from resilience-promoting training programmes.

Objectives: To assess the effects of interventions to foster resilience in healthcare students, that is, students in training for health professions delivering direct medical care (e.g. medical, nursing, midwifery or paramedic students), and those in training for allied health professions, as distinct from medical care (e.g. psychology, physical therapy or social work students).

Search methods: We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results.

Selection criteria: Randomised controlled trials (RCTs) comparing any form of psychological intervention to foster resilience, hardiness or post-traumatic growth versus no intervention, waiting list, usual care, and active or attention control, in adults (18 years and older), who are healthcare students. Primary outcomes were resilience, anxiety, depression, stress or stress perception, and well-being or quality of life. Secondary outcomes were resilience factors.

Data collection and analysis: Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post-test only).

Main results: We included 30 RCTs, of which 24 were set in high-income countries and six in (upper- to lower-) middle-income countries. Twenty-two studies focused solely on healthcare students (1315 participants; number randomised not specified for two studies), including both students in health professions delivering direct medical care and those in allied health professions, such as psychology and physical therapy. Half of the studies were conducted in a university or school setting, including nursing/midwifery students or medical students. Eight studies investigated mixed samples (1365 participants), with healthcare students and participants outside of a health professional study field. Participants mainly included women (63.3% to 67.3% in mixed samples) from young adulthood (mean age range, if reported: 19.5 to 26.83 years; 19.35 to 38.14 years in mixed samples). Seventeen of the studies investigated group interventions of high training intensity (11 studies; > 12 hours/sessions), that were delivered face-to-face (17 studies). Of the included studies, eight compared a resilience training based on mindfulness versus unspecific comparators (e.g. wait-list). The studies were funded by different sources (e.g. universities, foundations), or a combination of various sources (four studies). Seven studies did not specify a potential funder, and three studies received no funding support. Risk of bias was high or unclear, with main flaws in performance, detection, attrition and reporting bias domains. At post-intervention, very-low certainty evidence indicated that, compared to controls, healthcare students receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.43, 95% confidence interval (CI) 0.07 to 0.78; 9 studies, 561 participants), lower levels of anxiety (SMD -0.45, 95% CI -0.84 to -0.06; 7 studies, 362 participants), and lower levels of stress or stress perception (SMD -0.28, 95% CI -0.48 to -0.09; 7 studies, 420 participants). Effect sizes varied between small and moderate. There was little or no evidence of any effect of resilience training on depression (SMD -0.20, 95% CI -0.52 to 0.11; 6 studies, 332 participants; very-low certainty evidence) or well-being or quality of life (SMD 0.15, 95% CI -0.14 to 0.43; 4 studies, 251 participants; very-low certainty evidence). Adverse effects were measured in four studies, but data were only reported for three of them. None of the three studies reported any adverse events occurring during the study (very-low certainty of evidence).

Authors' conclusions: For healthcare students, there is very-low certainty evidence for the effect of resilience training on resilience, anxiety, and stress or stress perception at post-intervention. The heterogeneous interventions, the paucity of short-, medium- or long-term data, and the geographical distribution restricted to high-income countries limit the generalisability of results. Conclusions should therefore be drawn cautiously. Since the findings suggest positive effects of resilience training for healthcare students with very-low certainty evidence, high-quality replications and improved study designs (e.g. a consensus on the definition of resilience, the assessment of individual stressor exposure, more attention controls, and longer follow-up periods) are clearly needed.

Trial registration: ClinicalTrials.gov NCT00892138 NCT02867657 NCT03669016 NCT03903978 NCT04064372 NCT04416074.

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Conflict of interest statement

Angela Kunzler: none known. Isabella Helmreich is a board‐certified cognitive‐behaviour therapist. Jochem König: none known. Andrea Chmitorz is a board‐certified cognitive‐behaviour therapist. Michèle Wessa is a board‐certified cognitive‐behaviour therapist. Harald Binder: none known. Klaus Lieb (KL) is a board‐certified cognitive‐behaviour therapist with a special interest in schema therapy, and an Editor with Cochrane Developmental, Psychosocial and Learning Problems. KL received funding for this review from the Ministry of Science (MWWK) of the State Rhineland‐Palatinate, Germany.

Figures

1
1
Study flow diagram for all searches.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Study flow diagram for first searches (January 1990 to October 2016). aOne ongoing study in the box above is now awaiting classification.
5
5
Study flow diagram for second searches (October 2016 onwards).
aPeng 2014; Galante 2018.
6
6
Contour‐enhanced funnel plot of comparison 1: Resilience intervention vs control, healthcare students, Resilience: post‐intervention.
7
7
Contour‐enhanced funnel plot of comparison 1: Resilience intervention vs control, healthcare students, Anxiety: post‐intervention.
8
8
Contour‐enhanced funnel plot of comparison 1: Resilience intervention vs control, healthcare students, Depression: post‐intervention.
9
9
Contour‐enhanced funnel plot of comparison 1: Resilience intervention vs control, healthcare students, Stress or stress perception: post‐intervention.
10
10
Contour‐enhanced funnel plot of comparison 1: Resilience intervention vs control, healthcare students, Well‐being or quality of life: post‐intervention.
1.1
1.1. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 1: Resilience: post‐intervention
1.2
1.2. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 2: Resilience: short‐term follow‐up (≤ 3 months)
1.3
1.3. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 3: Resilience: medium‐term follow‐up (> 3 to ≤ 6 months)
1.4
1.4. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 4: Anxiety: post‐intervention
1.5
1.5. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 5: Anxiety: short‐term follow‐up (≤ 3 months)
1.6
1.6. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 6: Depression: post‐intervention
1.7
1.7. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 7: Depression: short‐term follow‐up (≤ 3 months)
1.8
1.8. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 8: Stress or stress perception: post‐intervention
1.9
1.9. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 9: Stress or stress perception: short‐term follow‐up (≤ 3 months)
1.10
1.10. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 10: Stress or stress perception: medium‐term follow‐up (> 3 to ≤ 6 months)
1.11
1.11. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 11: Well‐being or quality of life: post‐intervention
1.12
1.12. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 12: Well‐being or quality of life: short‐term follow‐up (≤ 3 months)
1.13
1.13. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 13: Social support: post‐intervention
1.14
1.14. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 14: Social support: short‐term follow‐up (≤ 3 months)
1.15
1.15. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 15: Optimism: post‐intervention
1.16
1.16. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 16: Self‐efficacy: post‐intervention
1.17
1.17. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 17: Self‐efficacy: short‐term follow‐up (≤ 3 months)
1.18
1.18. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 18: Active coping: post‐intervention
1.19
1.19. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 19: Active coping: short‐term follow‐up (≤ 3 months)
1.20
1.20. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 20: Self‐esteem: short‐term follow‐up (≤ 3 months)
1.21
1.21. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 21: Positive emotions: post‐intervention
1.22
1.22. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 22: Positive emotions: short‐term follow‐up (≤ 3 months)
1.23
1.23. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 23: Resilience: post‐intervention, sensitivity analysis (fixed‐effect analysis)
1.24
1.24. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 24: Anxiety: post‐intervention, sensitivity analysis (fixed‐effect analysis)
1.25
1.25. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 25: Depression: post‐intervention, sensitivity analysis (fixed‐effect analysis)
1.26
1.26. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 26: Stress or stress perception: post‐intervention, sensitivity analysis (fixed‐effect analysis)
1.27
1.27. Analysis
Comparison 1: Resilience interventions versus control conditions in healthcare students: primary and secondary outcomes, Outcome 27: Well‐being or quality of life: post‐intervention, sensitivity analysis (fixed‐effect analysis)
See this image and copyright information in PMC

References

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Venieris 2017 {published data only}
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References to studies awaiting assessment

Arch 2014 {published data only}
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Beadel 2016 {published data only}
    1. Beadel JR, Mathews A, Teachman BA. Cognitive bias modification to enhance resilience to a panic challenge. Cognitive Therapy and Research 2016;40(6):799–812. [DOI: 10.1007/s10608-016-9791-z] - DOI
Chen 2018b {published data only}
    1. Chen CY. A study of group intervention on depression in urban college students. Basic & Clinical Pharmacology & Toxicology 2018;122(Suppl 2):17-18. [DOI: 10.1111/bcpt.12968] [HHME17-TH04] - DOI
Clark 2019 {published data only}
    1. Clark CM, Gorton KL. Cognitive rehearsal, HeartMath, and simulation: an intervention to build resilience and address incivility. Journal of Nursing Education 2019;58(12):690-7. [DOI: 10.3928/01484834-20191120-03] [PMID: ] - DOI - PubMed
Crane 2020 {published data only}
    1. Crane MF, Kangas M, Karin E, Searle B, Chen D. Leveraging the experience of stressors: the role of adaptive systematic self-reflection. Anxiety, Stress & Coping 2020;33(3):231-47. [DOI: 10.1080/10615806.2020.1732359] [PMID: ] - DOI - PubMed
Despeaux 2019 {published data only}
    1. Despeaux KE, Lating JM, Everly GS Jr, Sherman MF, Kirkhart MW. A randomized controlled trial assessing the efficacy of group Psychological First Aid. Journal of Nervous and Nental Disease 2019;207(8):626-32. [DOI: 10.1097/NMD.0000000000001029] [PMID: ] - DOI - PubMed
DRKS00011265 {published data only}
    1. DRKS00011265. Efficacy and cost efficacy of an internetbased, unguided self-help intervention (StudiCare: Resilienz) for improving resilience in students. www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DR... (first received 18 January 2017).
DRKS00013765 {published data only}
    1. DRKS00013765. Efficacy and cost efficacy of an internetbased, unguided selfhelp intervention (StudiCare: Resilienz) for improving resilience in resilient students. www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DR... (first received 10 April 2018).
Enrique 2019 {published data only}ISRCTN11866034
    1. Enrique A, Mooney O, Salamana-Sanabria A, Lee CT, Farrell S, Richards D. Assessing the efficacy and acceptability of an internet-delivered intervention for resilience among college students: a pilot randomised control trial protocol. Internet Interventions 2019;17:100254. [DOI: 10.1016/j.invent.2019.100254] [PMC6603299] [PMID: ] - DOI - PMC - PubMed
    1. ISRCTN11866034. Assessment of the effectiveness and acceptability of an online intervention for adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress [Assessing the efficacy and acceptability of an Internet-delivered intervention for resilience: a pilot study for a randomised control trial]. www.isrctn.com/ISRCTN11866034 (first received 3 February 2019).
Flett 2020 {published data only}
    1. Flett JAM, Conner TS, Riordan BC, Patterson T, Hayne H. App-based mindfulness meditation for psychological distress and adjustment to college in incoming university students: a pragmatic, randomised, waitlist-controlled trial. Psychology & Health 2020 Feb 12 [Epub ahead of print]. [DOI: 10.1080/08870446.2019.1711089] - DOI - PubMed
Games 2020 {published data only}
    1. Games N, Thompson CL, Barrett P. A randomised controlled trial of the Adult Resilience Program: a universal prevention program. International Journal of Psychology 2020;55(S1):78-87. [DOI: 10.1002/ijop.12587] - DOI - PubMed
Gerson 2013 (study 1) {published data only}
    1. Gerson MW, Fernandez N. PATH: a program to build resilience and thriving in undergraduates. Journal of Applied Social Psychology 2013;43(11):2169-84. [DOI: 10.1111/jasp.12168] - DOI
Gerson 2013 (study 2) {published data only}
    1. Gerson MW, Fernandez N. PATH: a program to build resilience and thriving in undergraduates. Journal of Applied Social Psychology 2013;43(11):2169-84. [DOI: 10.1111/jasp.12168] - DOI
Harrer 2018 {published data only}
    1. DRKS00010212. Online based self-help stress management program for students with feedback on demand. www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DR... (first received 12 May 2016).
    1. Harrer M, Adam SH, Fleischmann RJ, Baumeister H, Auerbach R, Bruffaerts R, et al. Effectiveness of an internet- and app-based intervention for college students with elevated stress: randomized controlled trial. Journal of Medical Internet Research 2018;20(4):e136. [DOI: 10.2196/jmir.9293] [PMC5938594] [PMID: ] - DOI - PMC - PubMed
Heath 2020 {published data only}
    1. Heath J, Walmsley LA, Aker RM, Ferrin S, Stone D, Norton JC. CPR to the rescue! An interprofessional pilot program: cultivating practices for resilience (CPR) camp. Clinical Nurse Specialist 2020;34(2):63-9. [DOI: 10.1097/NUR.0000000000000506] [PMID: ] - DOI - PubMed
Herrero 2019 {published data only}
    1. Botella C, Baños R, Ebert D, Berger T, Schaub M, Garcia-Palacios A, et al. ICARE-R: an internet-based intervention for promoting resilience in freshmen university students. Cyber Therapy & Rehabilitation 2016;9(1):46-7. [www.cybertherapyandrehabilitation.com/2017/03/full-issue-91-2/]
    1. Herrero R, Mira A, Cormo G, Etchemendy E, Baños R, Garciá-Palacios A, et al. An internet based intervention for improving resilience and coping strategies in university students: study protocol for a randomized controlled trial. Internet Interventions 2019;16:43-51. [DOI: 10.1016/j.invent.2018.03.005] [PMC6364440] [PMID: ] - DOI - PMC - PubMed
ISRCTN17156687 {published data only}ISRCTN17156687
    1. ISRCTN17156687. Study of a smartphone-delivered, therapist-supported mindfulness-based therapy program for depression in Finnish university students [Randomized controlled study of a smartphone-delivered, therapist-supported, mindfulness-based intervention for depression in Finnish university students]. www.isrctn.com/ISRCTN17156687 (first received 24 June 2018).
Jackson 2019 {published data only}
    1. Jackson AC. The Efficacy of Coaching Interventions for Undergraduates to Increase Positive Coping Behavior: A Quantitative Quasi-Experiment [PhD thesis]. Portland (OR): Concordia University, 2019.
Kanekar 2010 {published data only}
    1. Kanekar A, Sharma M, Atri A. Enhancing social support, hardiness, and acculturation to improve mental health among Asian Indian international students. International Quarterly of Community Health Education 2010;30(1):55-68. [DOI: 10.2190/IQ.30.1.e] [PMID: ] - DOI - PubMed
Kon 2019 {published data only}
    1. Kon RH, Flickinger TE, Schorling J, May N, Owens JE, Harrison M, et al. Flourishing in the clerkship year: a longitudinal curriculum introducing skills to reduce burnout and foster resilience in medical students. Journal of General Internal Medicine 2019;34(2):S809. [DOI: 10.1007/s11606-019-05007-5] - DOI
Liu 2016 {published data only}
    1. Liu L, Zhang X, Song L. Research on the intervention of positive group psychology counseling on the resilience of college students. Advances in Social Science, Education and Humanities Research 2016;40:53-5. [DOI: 10.2991/icelaic-16.2017.13] - DOI
Liu 2019 {published data only}
    1. Liu JJW, Reed M, Vickers K. Reframing the individual stress response: Balancing our knowledge of stress to improve responsivity to stressors. Stress & Health 2019;35(5):607-16. [DOI: 10.1002/smi.2893] - DOI - PubMed
NCT02867657 {published data only}
    1. NCT02867657. Bringing the practice of mindfulness into nature - preventing mental fatigue in healthcare professionals [Enhancement of presence, compassion and resilience bringing the practice of mindfulness into nature - preventing mental fatigue in healthcare professionals]. clinicaltrials.gov/ct2/show/NCT02867657 (first received 10 August 2016).
NCT03669016 {published data only}
    1. NCT03669016. MIndfulness for students (Mindfulstud) [Mindfulness for students]. clinicaltrials.gov/ct2/show/NCT03669016 (first received 31 August 2018).
NCT03903978 {published data only}
    1. NCT03903978. Efficacy and effectiveness of a self-applied online program to promote resilience and coping skills in college students [Efficacy and effectiveness of a self-applied online program to promote resilience and coping skills in university students in three Spanish-speaking countries: study protocol for a randomized controlled trial]. clinicaltrials.gov/show/nct03903978 (first received 18 September 2018).
NCT04064372 {published data only}
    1. NCT04064372. Mindful response to adversity: a brief stress resilience training [Mindful response to adversity: a brief stress resilience training for improving mental health in students]. clinicaltrials.gov/ct2/show/NCT04064372 (first received 1 January 2019).
NCT04416074 {published data only}
    1. NCT04416074. An online 5-week professional identity group psychotherapy [An online 5-week professional identity group psychotherapy for nursing student during clinical rotation practice]. clinicaltrials.gov/ct2/show/NCT04416074 (first received 30 May 2020).
Noormohamadi 2019 {published data only}
    1. Noormohamadi SM, Arefi M, Afshaini K, Kakabaraee K. The effect of rational-emotive behavior therapy on anxiety and resilience in students. International Journal of Adolescent Medicine and Health 2019 Jun 8 [Epub ahead of print]. [DOI: 10.1515/ijamh-2019-0099] [ijamh.ahead-of-print/ijamh-2019-0099/ijamh-2019-0099.xml] [PMID: ] - DOI - PubMed
Oman 2008 {published data only}
    1. Oman D, Shapiro SL, Thoresen CE, Plante TG, Flinders T. Meditation lowers stress and supports forgiveness among college students: a randomized controlled trial. Journal of American College Health 2008;56(5):569-78. [DOI: 10.3200/JACH.56.5.569-578] [PMID: ] - DOI - PubMed
    1. Shapiro SL, Brown KW, Thoresen C, Plante TG. The moderation of mindfulness-based stress reduction effects by trait mindfulness: results from a randomized controlled trial. Journal of Clinical Psychology 2011;67(3):267-77. [DOI: 10.1002/jclp.20761] [PMID: ] - DOI - PubMed
Palma‐Gómez 2020 {published data only}
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Roghanchi 2013 {published data only}
    1. Roghanchi M, Mohamad AR, Mey SC, Momeni KM, Golmohamadian M. The effect of integrating rational emotive behavior therapy and art therapy on self-esteem and resilience. The Arts in Psychotherapy 2013;40(2):179-84. [DOI: 10.1016/j.aip.2012.12.006] - DOI
Seligman 2007 {published data only}
    1. Seligman ME, Schulman P, Tryon AM. Group prevention of depression and anxiety symptoms. Behaviour Research and Therapy 2007;45(6):1111-26. [DOI: 10.1016/j.brat.2006.09.010] [PMID: ] - DOI - PubMed
Tollefson 2018 {published data only}
    1. Tollefson M, Kite B, Matuszewicz E, Dore A, Heiss C. Effectiveness of student-led stress reduction activities in the undergraduate classroom on perceived student stress. College Student Journal 2018;52(4):505-15. [www.ingentaconnect.com/content/prin/csj/2018/00000052/00000004/art00010;...
Xu 2019 {published data only}
    1. Xu YY, Wu T, Yu YJ, Li M. A randomized controlled trial of well-being therapy to promote adaptation and alleviate emotional distress among medical freshmen. BMC Medical Education 2019;19(1):182. [DOI: 10.1186/s12909-019-1616-9] [PMC6547604] [PMID: ] - DOI - PMC - PubMed
Ye 2016 {published data only}
    1. Ye YS, Zhang ZX, Ye L, Bao CY. Impact of emotional resilience training upon psychological safety of undergraduate nursing interns. Chinese Journal of Modern Nursing 2016;22(18):2633-6. [No DOI or other object identifier available]
Zhang 2018 {published data only}
    1. Zhang H. Influence of wisdom education on psychological resilience of college students in frustration situation. Indian Journal of Pharmaceutical Sciences 2018;80(Suppl 1):50-1. [Poster 130] [www.ijpsonline.com/supplementary-files/supplement-to-issue-1-jan-feb.pdf]

References to ongoing studies

Harrer 2019 {published and unpublished data}
    1. DRKS00011800. Online based self-help stress management program for distance-learning students with feedback on demand [Online based self-help stress management program for distance-learning students with feedback on demand - StudiCare]. who.int/trialsearch/Trial2.aspx?TrialID=DRKS00011800 (first received 27 February 2017).
    1. Harrer M, Apolinário-Hagen J, Fritsche L, Drüge M, Krings L, Beck K, et al. Internet- and app-based stress intervention for distance-learning students with depressive symptoms: protocol of a randomized controlled trial. Frontiers in Psychiatry 2019;10:361. [DOI: 10.3389/fpsyt.2019.00361] [PMC6537513] [PMID: ] - DOI - PMC - PubMed
NL7623 {published data only}
    1. NL7623. DEcrease STress through RESilience training for Students. who.int/trialsearch/Trial2.aspx?TrialID=NL7623 (first received 22 March 2019).
Wild 2018 {published data only}ISRCTN16493616
    1. ISRCTN16493616. A study of resilience training for student paramedics [Preventing PTSD, depression, and associated health problems in student paramedics: a randomised controlled trial of internet-delivered cognitive training for resilience (iCT-R)]. isrctn.com/ISRCTN16493616 (first received 1 October 2017).
    1. Wild J, El-Salahi S, Tyson G, Lorenz H, Pariante CM, Danese A, et al. Preventing PTSD, depression and associated health problems in student paramedics: protocol for PREVENT-PTSD, a randomised controlled trial of supported online cognitive training for resilience versus alternative online training and standard practice. BMJ Open 2018;8(12):e022292. [DOI: 10.1136/bmjopen-2018-022292] [PMC6318590] [PMID: ] - DOI - PMC - PubMed

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References to other published versions of this review

Helmreich 2017
    1. Helmreich I, Kunzler A, Chmitorz A, König J, Binder H, Wessa M, et al. Psychological interventions for resilience enhancement in adults. Cochrane Database of Systematic Reviews 2017, Issue 2. Art. No: CD012527. [DOI: 10.1002/14651858.CD012527] - DOI - PMC - PubMed

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